For healthier newborns, Oregon hospitals try to ensure more time in the womb

View full sizeDoug Beghtel/The OregonianKatie Bock of Camas considered scheduling her C-section a few days early, but in accordance with a new policy at Legacy Salmon Creek Hospital, she and her doctor agreed to wait for a full 39-week gestation for her baby, Austin, now 2 months old.

As her due date approached, Katie Bock felt a yearning common in late pregnancy. Her developing baby boy was bigger than usual. And because she was planning a cesarean delivery, she wondered whether the birth could be scheduled a few days early.

"I was ready to be done, that's for darn sure," the Camas resident says. But her obstetrician, Dr. Suzanne Slayton-Milam, insisted she wait for the baby to reach 39 weeks gestation before going ahead with the delivery.

"Even though he was big she really stood firm," Bock said. "She said it's in the baby's best interest."

While it's become common for hospitals to schedule induced or surgical births as early as 37 weeks, researchers have come to understand how critical the final weeks and days in the womb can be for healthy development. Now hospitals in Oregon and across the U.S. are trying to stop hastening deliveries for non-medical reasons.

Legacy Salmon Creek Hospital, where Bock had her baby, is one of the first in the region to stop allowing elective inductions and C-sections before 39 weeks gestation, unless they are justified for medical reasons. At least 17 Oregon hospitals have committed to enforcing a similar policy by Sept. 1.

Births often scheduled too early

Here's a comparison of the rates of scheduled deliveries between 37 and 39 weeks at hospitals that have voluntarily disclosed their results to The Leapfrog Group, a nonprofit organization that compares hospital quality and safety:

35.0% -- Providence Portland Medical Center

31.9% -- Mid-Columbia Medical Center, The Dalles

30.4% -- Kaiser Sunnyside Medical Center, Clackamas

24.0% -- Providence St. Vincent Medical Center, Portland

22.5% -- Southwest Washington Medical Center, Vancouver

12.0% -- Providence Milwaukie Hospital

3.2% -- Providence Newberg Medical Center

0% -- Providence Medford Medical Center

During the last few weeks of pregnancy, the developing infant brain nearly doubles in weight, researchers have found. Vital organs including the kidneys, liver and lungs undergo significant development after 37 weeks of gestation. Ten percent of infants delivered before 39 weeks experience complications, and the risk of dying is nearly two times higher among infants born at 37 weeks compared with those born at 40 weeks, according to the March of Dimes Foundation. The nonprofit is leading a national campaign, called "Healthy Babies Are Worth the Wait," to educate mothers-to-be and their medical caregivers about the risks of births scheduled before full term.

At hospitals in Oregon and across the U.S., it's not unusual for doctors to schedule 30 percent or more of elective deliveries before 39 weeks. The rate of elective deliveries between 37 and 39 weeks is about 35 percent at Providence Portland Medical Center, and 30 percent at Kaiser Sunnyside Medical Center in Clackamas, according to the nonprofit Leapfrog Group, which compares hospital quality.

"There are a lot of drivers that got us to where we are," says Dr. David Labby, medical director of CareOregon, a health plan that specializes in serving low-income and disabled populations with government-funded health coverage.

Among the most important factors is the perception among women and health professionals that induction of labor is convenient and safe. The practice allows mothers-to-be to schedule support, maternity leave, and other arrangements. Doctors get to arrange their schedules and attend fewer births at unpredictable times. Hospitals get to staff nurses in advance for an expected number of births.

"With technology and wanting to schedule our lives, we've shifted toward setting a time of birth that's best for us, not best for the baby," says Joanne Rogovoy with the March of Dimes Foundation in Oregon.

Women planning to have children often don't understand the risks of early induction. In a 2009 national survey of 650 women who recently gave birth, more than half incorrectly said a pregnancy reaches full term at 37 weeks and that they considered it safe to deliver at 34 weeks. Less than 1 in 10 correctly said a healthy gestation takes 39 weeks.

Routine use of ultrasound and other tests in low-risk women may also be raising unwarranted fears about fetal condition, and prompting greater use of labor inducing drugs or cesarean surgery to hasten birth. Scans, for instance, could suggest that a developing baby is unusually large or that the amniotic fluid level is low.

But emerging evidence suggests that many thousands of induced births and cesarean births are done too early without any medical basis.

"Improvements in neonatal care, with better and better outcomes, just created a perception that a couple weeks early was probably OK. But of course we are finding that not to be the case," says Helen Phillips, a registered nurse and director of women's services at Legacy Emanuel Medical Center.

As the evidence of harms from early scheduled births grew more and more compelling, "people realized we need to change this," Labby says.

In Washington, the state Medicaid program in 2009 began using financial rewards and penalties to eliminate medically unnecessary induced births and c-sections. The agency cut the payment for uncomplicated C-sections and began paying a bonus to hospitals that reduced the rate of early scheduled deliveries. A collaborative of obstetric providers set a goal for hospitals to reduce their rate of elective deliveries done earlier than 39 weeks to 7 percent.

View full sizeDoug Beghtel/The OregonianKatie Bock, from Camus, considered scheduling her c-section a few days early, but in accordance with a new policy at Legacy Salmon Creek Hospital, she and her doctor agreed to wait for a full 39-week gestation for her baby. Austin is now two months old.

Oregon hospitals hope to replicate the success of others, such as Intermountain Healthcare in Utah and Idaho. Rogovoy says the Intermountain hospitals managed to lower their rate of early scheduled deliveries from 28 percent to less than 3 percent. A collaborative of hospitals in Ohio went from 25 percent to below 5 percent within 14 months.

A few Oregon hospitals have achieved very low rates. Providence Newberg Medical Center reported 3.2 percent and Providence Medford Medical Center reported a rate of zero elective births before 39 weeks in the Leapfrog ratings, which exclude medically indicated early inductions and C-sections.

"We're never gonna get overall rates to zero," Labby says. "There are some valid and clinically important reasons to do this. But we don't want to use medical intervention where the natural birth process is the preferred option."